Context: The problem of left behind radiological investigations is encountered round the world, which adds to the wastage of resources. Aims: This article attempts to highlights the problem of left behind conventional radiographs in an emergency setting in a tertiary care center of northern India. Settings and Design: Tertiary care center, retrospective study. Materials and Methods: The number of radiographs left behind in the emergency over a period of 14 months was retrospectively assessed. The radiographs were classified as normal, abnormal and technically poor. The technically poor radiographs included the ones with poor centering, inadequate inspiration and improper exposure factors limiting the interpretation. Statistical Analysis Used: Discrete categorical data is presented as n (%). Results: A total of 2783 radiographs were left behind. The total cost of these left out radiographs worked out to 139,150 Indian rupees. Of the 2783 radiographs, 1108 had positive findings (39.8%) and 1399 were normal (50.2%). The technically poor radiographs were 276 (10%) and no definite conclusion could be given as no clinical history was provided in the majority of these cases. Conclusions: A joint cost-effective strategy should be formulated by hospital administration, radiology and allied departments to overcome the problem of ever increasing bundles of left out radiography, especially in the developing countries having resource-poor settings.
Keywords: Emergency, left, limited, radiographs, resources
The number of radiological investigations is increasing in an exponential fashion around the world. Of these, conventional radiography is commonly used as an initial screening modality due to its easy availability, rapidity and the cost effectiveness. Patients presenting to the emergency department with medical or surgical complaints usually undergo conventional radiography of the region concerned for appropriate course of action. However, many of these are not collected by the patients resulting in a significant burden in terms of availability of space. The cost involved implications on further management, medicolegal importance and storage nuisance are significant. This problem is of great magnitude especially in the developing countries with resource-poor settings and should be appropriately addressed. This study was conducted to quantify the problem of left behind radiographs in an emergency setting.
This was a retrospective study conducted in the emergency radiography section of a tertiary care center of the Northern India. Our hospital has 1948 beds, of which 208 beds are in the different medical and surgical observation wards. The emergency radiography section of our department handles the medical and surgical emergency out-patient departments, medical and surgical emergency wards, intensive care units (ICUs), trauma, bedside radiography and all in-patient wards (on an emergency basis). The films are issued to the patients as early as possible. Picture archiving and communications system (PACS) is not fully functional in our set up at present.
The number of radiographs that had been left behind by the patients between September 2010 and October 2011 were retrospectively assessed. The radiographs were classified as normal, abnormal and technically poor. The technically poor radiographs included the ones with poor centering, inadequate inspiration and improper exposure factors limiting the interpretation.
A total of 96,033 radiographs were done in the emergency radiography section during the study period.
[Table 1] summarizes data of the left behind radiographs categorized according to the different wards.
A total of 2783 radiographs were left behind. The total cost of these left out radiographs worked out to 139,150 Indian rupees.
Of the 2783 radiographs, 1108 had positive findings (39.8%) and 1399 were normal (50.2%). The technically poor radiographs were 276 (10%) and no definite conclusion could be given as no clinical history was provided in the majority of these cases.
Of all the radiographs left behind, maximum radiographs were from the different surgical wards accounting for 695 of 2783 radiographs (24.9%). Of these 695 radiographs, 275 radiographs were abnormal (39.6%).
[Figure 1] and [Figure 2] summarize the distribution of the radiographs by clubbing up of the different wards. The emergency medical included the emergency medicine out-patient department and emergency medicine ward. The emergency surgical out-patient department, emergency surgery wards, trauma wards and operation theatres were clubbed up under emergency surgical category. The rest category included the left out documented wards.
The patients in the emergency surgical wards are usually the post-operative patients who have undergone emergency surgeries (in our center) including the head injuries, abdominal trauma or the referred cases from outside with eventful post-operative period due to complications, which occurred during the surgeries. The left behind radiographs (505 of 2783) from these emergency surgical wards were maximum (18.1%), of which 216 were abnormal (42.8%).
The bed side radiography is done on an extremely urgent basis in ICUs, operation theaters, emergency medical and surgical wards as the patients are bed ridden, on various life supports and cannot be shifted to the radiography room. These left out portable radiographs accounted to be 663 of 2783 (23.8%). Of these 663 radiographs, 66 radiographs were technically poor (10%). The technically poor radiographs from ICUs were maximum in number, 33 of 218 (15%), among the wards mentioned in the requisition forms. In the left over radiographs from ICUs, 126 (46.3%) radiographs were normal.
The problem of left behind radiological investigations is encountered by the radiological departments round the globe and is increasing with an increase in number of different imaging modalities.
Plain radiography is used as a screening modality in most of patients presenting to clinical departments, especially in an emergency setting. A study dealing with assessment of left out conventional radiography only in an emergency set up in a tertiary care center has not been documented before in the literature. However, two studies have been documented which evaluated the problem of left out investigations including radiographs, ultrasounds, computed tomography and magnetic resonance imaging in different combinations. ,
Govindswamy et al.  analyzed the total radiographs left behind in the department while we focused on the emergency department only. In their study, 1424 radiographs were left behind of which 658 (46.2%) were normal and 766 (53.8%) were abnormal. In our study however, left out normal radiographs were more than the abnormal radiographs. In the study conducted by Govindswamy et al.,  maximum abnormal radiographs were from the orthopedics department (510/658, 77.5%), while in our study were from the emergency surgical wards (131/1108, 11.8%). The left abnormal orthopedic radiographs including the poor quality radiographs accounted to a small number in our study (53/1384, 3.8%). This could just be a chance variation. However, the likely cause for the low proportion of poor quality radiographs could be the use of high quality digital radiography system available in our emergency radiography section.
In our study, only in the emergency section itself, 2783 radiographs were left behind. If the data are extrapolated to include the left out non-emergency radiographs as well as other investigations, the total financial burden is of enormous magnitude. This is likely due to a large number of patients handled by our center. This data supports the statement that the problem of left behind radiographs is larger than anticipated when one looks on a larger scale. 
There are many problems faced by patients, physicians, radiology department as well the hospital administration due to left out radiographs.
Patients, in our setting, are shifted toward or are discharged from the emergency depending upon the clinical situation. In case, radiograph is not collected by the patient, he might have to undergo the study again (even if previous study might have been normal) in view of non-availability of record after he has left emergency. This again increases the radiation exposure and cost to the patient as well as wastage of time of the patient, referring physician as well as the technologist. Due to non-availability of previously done radiograph, physician at times is not able to assess the progression of the disease as well as faces difficulty in framing a probable diagnosis and its differentials. These left out radiographs require storage space, which is always a constraint for any department.
The radiographs are done free of cost for the first 24 h for patients who have presented for the first time to our center in emergency section. The cost is entirely borne by the hospital administration and government. This fact is not realized and could be one of the possible reasons that few of the patients fail to collect radiographs because the cost initially is not borne by them.
Few of the patients ask about the result immediately at the end of the study. The knowledge of the result could be one of the reasons of their failure in collecting the radiograph, especially in cases of normal studies. The lack of awareness and the discomfort level in a large hospital faced by patients coming for the first time could possibly be another reason.
The hospital administration, radiology and the various referring departments should formulate a strategy to overcome the problem of ever increasing bundles of left out radiography, especially done on an emergency basis.
The requisition should be made for only those cases, in which the clinician thinks that the conventional radiography would actually help him out as a problem solving tool.
The referring clinician should look into the fact that the patient has collected the radiograph as early as possible. This is extremely important in case where significant findings are there. The patients should be educated about the hazards of radiation and importance of collecting previous study for future course of action.
The referring clinician should also pay a little more attention in completely filling the forms (in particular the referral ward) to make the communication easier, especially in case of significant findings.
Left behind technically poor radiographs are mostly the ones done on a portable machine. The patients are bed ridden and it is difficult to achieve a satisfactory position as well as adequate inspiration, especially in chest radiography. This problem can be tackled again by requesting for only those in which the radiograph would actually be cost-effective from the management point of view.
PACS is not fully functional in our set up. The introduction of PACS connecting the radiology and the other departments might be helpful. PACS is fruitful and cost-effective in a tertiary care center handling a lot many patients. The Clinician would then look into the image at the earliest and ask for the printing only if he feels it would be of benefit for future management. However, even if the study is normal, the film can be printed using high resolution laser printers on plain paper. This will reduce the film cost as well as require less storage space.  Further, wireless local area networking for linking a personal computer reporting system and PACS have been shown to be clinically feasible in emergency reporting. 
However, the transition from traditional film images to PACS is a challenging and often difficult path,  especially in resource poor settings.
The problem of the left behind radiographs can be lessened by the joint venture of hospital administration, radiology and allied departments. In case of non-availability of the previously done left out radiograph, repeating the skiagram adds to the cost as well as the radiation exposure to the patient. These left out radiographs require storage space, which is always a constraint for any department. The normal radiographs can be printed using high resolution laser printers on plain paper. This will reduce the film cost as well as require less storage space. Through PACS, clinician can look into the image at the earliest and ask for the printing only if he feels it would be of benefit for future management.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]